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Thursday, May 29, 2014

Does a simple sore
throat lead to psychological symptoms such as obsessive compulsive disorder
(OCD) or Tourette syndrome?

In 1998, physicians
began reporting odd encephalitis (brain inflammation)-like symptoms following an
infection with Group A beta-hemolytic Streptococcus (GABHS), a bacterial
infection.

Currently, PANDAS is
not an ICD-9 recognized disease, and there is no recommended treatment. The suggested
diagnostic criteria for PANDAS is abrupt onset (or dramatic exacerbations) of
OCD or tic disorder, beginning between 3yo and the start of puberty, that
occurs following an infection with GABHS. The neurologic examination would
reveal hyperactivity, choreiform (snake-like) movements and/or tics.

Several studies have explored
this phenomenon with conflicting results. Some authors found no correlation,
while others found only elevated ASO (antibody) titers or the worsening of
preexisting tic or OCD disorders. While some retrospective studies verified an
association between infection and these neurological changes, a direct
relationship has not been established.

Many clinicians think
that PANDAS is simply a misdiagnosis of Sydenham’s chorea, a criteria for acute
rheumatic fever (also caused by streptococcal infection) that is characterized
by spastic and purposeless movements of the face or arms. Similarly to
rheumatic fever, researchers believe that PANDAS may be due to the accidental production
of antibodies that attack an area of the brain known as the basal ganglia.

If your child
develops a sudden tic or movement disorder, or begins to display
uncharacteristic psychological behavior, it is important to contact your
physician. While PANDAS may be only temporary, acute rheumatic fever can lead
to serious heart problems.

A recent study by Vincer
et al published in the Journal of Pediatrics and Child Health reported on the
rates of preterm infant mortality and cerebral palsy (CP) over the last 20
years. They found that the birth prevalence of CP among very preterm infants (less
than 31 weeks) is on the rise, but the reasons are unclear.

CP is a permanent condition
caused by damage to motor control centers in the brain before or shortly after
birth, resulting in non-progressive impaired movement and permanent physical
disability. The affected child typically has problems with uncontrolled spastic
movements and/or impaired coordination of movement. Some cases are associated
with epilepsy, poor cognition and/or difficulty with communication.

Between 1988 and 2007, very
preterm infant mortality steadily declined while CP has been on the
upswing. Vincer et al notes that maternal risk factors, anemia and tocolytic use have
all been on the rise as well. Whether or not these represent a correlation has
yet to be determined.

Friday, May 23, 2014

Hirschsprung disease, also known as toxic
megacolon, is a life threatening intestinal obstruction seen in children.

When a fetus is developing in the womb, each
type of cell must successfully migrate to where it belongs and, once there,
perform their assigned duties. In this case, the cells, neuroblasts, do not
make it to their destination in the distal intestine or they arrive but forget
to do their job.

The condition is relatively rare, only
occurring in 1 in every 5,000 live births. It is four times more common in
males, and the risk is increased in Down syndrome or if a family history is
present.

One of the most telltale signs that an infant
is suffering from Hirschsprung Disease is the failure of an infant to pass his
or her first bowel movement, known as meconeum, within the first 24 hours of
life. Other signs include abdominal distention, bilious (yellow bile) vomiting,
jaundice and feeding intolerance.

Over 80% of cases occur in infants, but
occasionally the condition is seen in older children. In these cases, the child
may show signs of chronic constipation, abdominal distention, failure to
thrive, fever, diarrhea, vomiting, explosive stools and/or overflow
incontinence. These children typically have intermittent problems with having a
proper bowel movement, often on laxatives to ease their pain.

The pediatrician will do a physical
examination when he or she suspects intestinal obstruction, looking for
abdominal distention and a tight anal sphincter. An abdominal x-ray will typically
show a dilated section of bowel preceding the area of obstruction. If
enterocolitis is ruled out, a contrast enema will be performed, though this
test is only 70% sensitive (83% specific). The disease is confirmed by a
pathologist following a suction rectal biopsy performed by a surgeon.

If the child is over 12 months old, this
condition is very unlikely. Other conditions that may mimic this condition
include functional constipation, medication side effects, lead poisoning, sepsis,
intussusception, meconeum ileus, meckel diverticulum, hypothyroidism and
intestinal malrotation, atresia or stenosis.

Studies have shown that these infants,
especially if preterm, also have an increased risk for other congenital
abnormalities, such as heart problems, so a doctor may decide to do a thorough
workup.

The immediate treatment for Hirschsprung
Disease is to “decompress” the bowel obstruction using a nasogastric tube, antibiotics
and IV fluids. Once the child is stable, a surgeon will fix the abnormality by
removing the affected area of bowel (Pull-through procedure). If the surgery is
successful and infection (enterocolitis) is avoided, the prognosis is excellent
(<1% mortality) and the child will live a normal life.

Monday, May 19, 2014

Middle East Respiratory Syndrome (MERS) virus has
made its way into the United States after killing hundreds in the Middle East.
The MERS virus, first isolated in 2012, is a coronavirus that spreads through
respiratory droplets and causes a severe acute respiratory illness. Symptoms of
infection include fever, cough and shortness of breath.

MERS, similar to the flu, can be quite
dangerous to the elderly and those with compromised immune systems. Since it’s transmitted
following close human-to-human contact, family members caring for their sick
relatives can easily contract the virus. This seems to be why so many have been
infected in the Middle East: Owing to poor living conditions and the lack of
proper medical care, an estimated 30% of those infected have died.

Two confirmed cases have been reported in patients
traveling from the Arabian Peninsula to the United States.

On May 2, MERS was confirmed in an Indiana
hospital. The patient, a healthcare worker, had recently arrived from Saudi
Arabia following layovers in London and Chicago. He was isolated and
successfully treated. Shortly after, an Illinois resident whom had close
contact with the infected patient before his hospitalization began exhibiting
symptoms of infection. He tested positive for antibodies to the virus,
suggesting he suffered a very mild illness before fully recovering.

On May 11, MERS was reported in an Orlando
hospital. The patient, a healthcare worker, was traveling from Saudi Arabia and
reported layovers in London, Boston and Atlanta. He felt unwell during the
flight, so visited the Emergency Room after landing. He was successfully
treated and is currently in good health.

The current strain of MERS virus is not a
major threat to the United States. Still, communities of immuno-compromised
citizens in close quarters are at risk. It is for this reason that hospitals
and nursing homes across states like Florida are warning residents to stay
aware of the warning signs.

All viruses have the ability to mutate into a
deadlier strain

There is no evidence of sustained spreading in
community settings

If you’ve been in close contact with one of
the individuals infected by MERS, call your healthcare professional and inform
them promptly

Always wear a protective mask (such as N95) when
caring for a patient or relative with a cough and a fever

Reference

Middle East Respiratory Syndrome (MERS). Centers
for Disease Control and Prevention. Accessed May 19, 2014. http://www.cdc.gov/coronavirus/mers/index.html

Monday, May 12, 2014

The term "morbilliform" is used to describe any skin finding that resembles the measles rash. The macular lesions are typically diffuse, red and 2-10 mm in diameter. They may become confluent (come together to form clusters) in some areas.

It is very important for doctors to know the differential diagnosis for a morbilliform rash, since some of the conditions are deadly. The process occurring within the body leading up to the rash, known as the prodrome, will help the physician narrow the diagnosis.This prodrome can be learned by ascertaining a good history.

A study by Ramsay et al in 2002 evaluated the laboratory samples of 93 vaccinated children in England, and noted that the most common cause of the rash was a parvovirus B19 infection (17%). Group A strep was found in 15% of cases, and sixth disease (roseola infantum or herpesvirus 6) in 11%. None of the cases were caused by measles. The use of widespread vaccination has nearly eliminated the measles infection, making way for other viruses that cause similar rashes. It is paramount that physicians discern the cause of the findings.

Thursday, May 8, 2014

Cat Scratch Disease, also known as Cat Scratch
Fever, is found in more locations than just a Ted Nugent album. This disease, first isolated in 1992, is caused by a bacteria called Bartonella henselae and
affects roughly 6.6 in every 100,000 children in the United States. It's mostly benign (harmless), and in
some cases goes unnoticed. Every now and then, though, a mother may see this in her
child and become concerned:

The bacteria is transmitted
to cats, typically kittens, by fleas. When a child is scratched by the
cat, or in some cases pets the cat and then rubs his or her eye, the bacteria
enters their bloodstream.

In 2-3 weeks, the child will
develop lymphadenopathy, or the enlargement of the lymph nodes. The most common
location of the lymphadenopathy is in the neck (33% of cases), followed by the
axilla (underarm, 27%) and inguinal (groin, 18%). The child will also develop
the characteristic fever and may complain of a sore throat.

In children with weak immune
systems (immunocompromised), the disease may become disseminated (spread
throughout the body) and cause infection of the bone (osteomyelitis), brain
(encephalitis, resulting in seizures) and eye (oculoglandular conjunctivitis).
In children with heart valve problems, this disease may cause endocarditis
(infection of heart valve). For this reason, the CDC recommends that these children
and adults avoid playing with cats or kittens, especially those with fleas.

Since the disease goes away
on its own, a doctor will only need to prescribe pain medication for the
painful lymph nodes. There is limited evidence that antibiotics are helpful in
treating Cat Scratch Fever, so put on an old record and let Ted do all of the work.

Cases in adults are not
uncommon. 80% of patients with cat-scratch disease are < 21 years old

Cases of dogs, monkeys, porcupine quills and thorns have
been reported

The disease is not contagious. There are no reports of
person-to-person transmission

Laboratory diagnosis is difficult, since the organism can be
difficult to see. Currently, polymerase chain reaction (PCR) or Warthin-Starry
Stain is used

As E-cigarettes gain popularity, the liquid refill bottles are mistakingly making their way into the hands of children. NEJM recently reported a case of a 10 month old boy that presented with vomiting, tachycardia, grunting respirations and truncal ataxia.

Photo courtesy of NEJM

Check out the original article here:
http://www.nejm.org/doi/full/10.1056/NEJMc1403843

Tuesday, May 6, 2014

Good nutrition during the developing years of life has been
correlated with improved growth, body height, IQ, educational achievement and
hourly wage. Are you familiar with the current guidelines for infants,
adolescents and teens?

If family history of allergy or atopic dermatitis, using
breast milk or hypoallergenic hydrolyzed (casein or 100% whey protein) infant
formulas instead of cow’s milk formulas may reduce the risk in the child.

If infant was preterm or small for gestational age (SGA), nutrient-enriched
and soy formulas are not recommended.

Many formulas boast the addition of probiotics and long
chain polyunsaturated fatty acids (LCPUFA) to their products, but there is no
evidence that these are beneficial to the infant.

Age 4-6 months.
Begin to introduce single grain, iron-fortified cereal (1 tbsp cereal mixed
with 4tbsp breast milk, gradually increase the amount of cereal over time). Never
put cereal in a bottle! Sit child upright and feed to them with a spoon.

Cues that an infant is ready for solid foods include:

Doubled birth weight

Ability to sit up without support with control of head and
neck

Infant shows interest in foods parents are eating

Age 6-8 months. Once
all cereals have been tried, continue breast milk while gradually adding
solids. Begin introducing 1-2 tbsp of both fruits and vegetables, strained,
twice daily and increase to 2-3 tbsp. Try baby fruit juice in a cup and offer
finely chopped or mashed fruits and cooked vegetables once all strained
varieties have been tried. Introduce 1 food each week to determine which foods
are poorly tolerated. Start with single ingredient baby foods before
introducing mixed ones. Limit 1 serving per day of carrots, beets and spinach
(may cause methemoglobinemia) and never feed them honey.

Age 8-12 months. Introduce
finger foods in cups and encourage self-feeding (allow baby to get messy).Begin to add finely chopped meats, one
per week. Avoid sweetened beverages and foods that may get stuck in the throat
(nuts, raw carrots, round candies, hot dogs, apple pieces, grapes and chips). Introduce
no more than 4 ounces of unsweetened 100% fruit juice a day. Be sure to sit
child up straight in high chair while eating, and always taste heated foods
before serving. Do not restrict fat intake unless directed to do so by
pediatrician.

DISCLAIMER

This blog is not intended to, and does not, provide medical advice. All health care content available on or through this website is presented by the author for general informational purposes only and must not be regarded as a substitute for advice, diagnosis or treatment by a professional health care provider. In addition, this blog does not recommend or endorse, and disclaims all liability relating to, any particular products, procedures, opinions or other information presented or referred to on or through this website (including but not limited to the content of any advertisement).